Antianxiety agents and antidepressants which are commonly used as psychotropics for psychosomatic disorders are examined through tracing the history of pharmacotherapy from the viewpoint of psychosomatic medicine. Regarding antianxiety agents, the advantage of clinical evaluations over the object of autonomic imbalance is explained on the basis of the results of our examinations. Regarding antidepressants, mainly focusing on a selective serotonin reuptake inhibitor which has been under development in recent years, the reference to the clinical evaluation including the future tendency, is made on the basis of our performance. For antianxiety agents, the emergence of serotonin 1A agonist facilitates a new development, and the future development of a new antidepressant which is being developed, a selective serotonin reuptake inhibitor, is greatly expected.

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With the coming of the aging society, psychosomatic disorders in the elderly are on the increase year by year and the problems of their QOL are drawing our attention. Psychosomatic disorders in the elderly include the following characteristics : (1) chronic clinical course (2) difficulty in giving complete care (3) leaving functional disorders (4) complications of two or more diseases (5) frequent relapses (6) frequent complications (7) atypical clinical symptoms and courses (8) occurrence of iatrogenic diseases, etc. Excessive support and care for the elderly can induce heavy dependence up on the surrounding people. As the result, physical functioning of the elderly is lowered, which, in turn, exerts a negative influence upon their QOL. For the improvement of QOL from the psychosomatic viewpoint, maintenance of living conditions, increased opportunities for pursuing hobbies and recreation, and increased communication with families and friends are indispensable in addition to medical treatment.

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Current psychosomatic medicine has the purpose of establishing medical care systems, based upon the study results of psychosomatic or biopsychosocial interaction, which form the core of total patient care. The author has pointed out the tasks and problems of research, practice and education in psychosomatic medicine. The expected fields of psychosomatic medicine in the future include mechanism and coping strategy of stress-related disorders, self-care and prevention of life-style related disorders, health care and welfare of the aged, terminal care and psychooncology, rehabilitation, health science, mental health for workers, occupational medicine and preventive medicine, and puberty and adolescent medicine. The suggestions and supports from the standpoint of psychosomatic medicine are also desirable to the problems of child-rearing and school education.

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The 2lst century is characterized by aging society in many developed countries. In Japan, the ratio of elderly population 65 years old and above to the whole population is about 15% in 1996 and will be about 25% in the year 2025. We are really facing the exceptionally prominent aging society in the near future. Especially the increase in old-old population (over 75 years old) means immediately the increase in frail elderly requiring constant medical supervision and care. It is well known that frail elderly has numerous coping difficulties in socio-somato-psychic aspects and requires the holistic approach. This is the main reason why I would like to emphasize the importance of the role of psychosomatic medicine in our community in the future. There are several issues in health disorders in the elderly. 1) Close mind-body correlation As an example, depression or dementia might be triggered by the course of physical disease such as hip fracture or infectious disease. Inversely, bedfast state or general physical deterioration might appear in the course of depression, or dementia state. 2) Chronic course of illness Health disorders of the elderly tend to have both disease and disability caused by the disease. This situation requires individual consideration for quality of life of the elderly as well as close liaison between medical and welfare services in the community. 3) High incidence of syndrome related with cerebral aging Two syndromes are common and their incidence increase in higher age : one is acute brain syndrome, delirious state and the other is chronic brain syndrome, dementia state. Every primary care physicians are expected to have the clinical knowledge and skills to cope with both syndromes. 4) The importance of environmental factors The health state of the elderly might have been influenced by the unfavorable life events such as death of spouse, retirement or decreased economic income etc. which are inevitably experienced at old age. These life events might occur successively at relatively short intervals and might have possibility to give unexpected impact on psychosomatic condition. The clinician should be aware of the environmental factor in treating health disorders in the elderly. All these 4 characteristics of health disorders in the elderly clearly point to the important role of psychosomatic medicine. Here, I would like to report the holistic approach to the patients of Alzheimer type of dementia in the setting of day-care program at Department of Psychiatry of St. Marianna University Hospital. We had usually 7-8 patients with their family care-givers for one session of the group. The total number of dementia sufferers was 190 (average age 70 . 9 d : 8 . 4) and their 190 care-givers for the past 10 years. The purpose of day-care is as following : (1) to discover intact functions in each dementia patient and provide an opportunity for the patient to improve these functions ; (2) to increase social interaction with other members, and draw forth the spontaneity of each patient and (3) to support individual care-givers and to teach them the proper care of the patients. Along the group activity of day-care, we gave the extensive counseling service to each care-giver who is permitted to observe the group activities through oneside-mirror, and have an opportunity to observe objectively the caring technique to their demented elderlies. Although, there has been no siginificant change in cognitive function measured by Hasegawa's dementia scale, some of the activities of daily life improved after 4 months' session of day care. The care-givers started to understand and accepted the behavior of their elderly. As their caring behavior started to change, the behavior problems of their dementia patients started to decrease. Thus the holistic approach including both dementia sufferers and their care-giveres improve the quality of life of the elderly demented in

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The author addresses his personal view on the theoretical, investigative, and clinical aspects of psychosomatic medicine. The problem of assessing the relative contribution of biological, psychological, and social factors to the development, course, and outcome of physical illness, holds a dominant position in psychosomatic medicine. The disturbances include transient physiologic fluctuation associated with autonomic hyperactivity which is not considered pathological. In the personality study relevant to the field of psychosomatic medicine, the quantitative (dimensional) diagnosis, such as Cloninger's Temperament and Character Inventory (TCI) , may serve as more reliable sources than the conventional qualitative (categorical)personality diagnosis. The vulnerability/stress model proposed by Zubin for schizophrenia is also useful for investigating the onset and outcome of psychosomatic disorders. The model distinguishes the vulnerability as a persistent trait from the illness episodes which are time-limited states of longer or shorter duration, and which are triggered into expression by some stressor. Higher 'harm avoidance' scores of TCI are presumed to be a marker of the vulnerability. A sense of self-efficacy and successful coping of stressors, and also a creed or religion are important factors of relevance to stress resilience or salutogenesis. The recognition of transient nature of illness symptoms helps patients to hold an optimistic outlook on their illness. As to the principle of psychotherapy, we should notice that a good psychotherapist is a teacher who opens up new options which the patient was not previously aware of, and which aid the patient in finding his or her own coping strategies that will provide 'natural healing'.

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To distinguish the clinical features between psychosomatic illness and neurotic illness, 191 psychosomatic patients (male 39%) and 164 neurotic patients (male 43%) aged 25 to 65 years were diagnosed by the semi-structured interview using the Diagnostic and Statistical Manual of Mental Disorders third edition-revised (DSM-III-R) and these results were recorded in the database. The major diagnoses in the psychosomatic group were somatoform disorder not otherwise specified, bulimia nervosa, and psychological factors affecting physical condition. Similarly, those in the neurotic group were panic disorder with agoraphobia, hypochondriasis, and conversion. The numbers of patients with personality disorders were 33 (17%) in psychosomatic group and 34 (21%) in neurotic group, and the prevalence rates of personality disorder did not differ significantly between the two groups. The psychosocial stress score was lower in the psychosomatic group (none : 19%, mild : 61%, moderate : 17%, and severe- : 3%), compared with the neurotic group (none : 7%, mild : 65%, moderate : 23%, severe- : 5%) . The psychosocial and occupational functioning score was higher in the psychosomatic group (70.2±11.1), compared with the neurotic group (67.8±10.1)(Mean ± S.D.). Although the differences between psychosomatic illness and neurotic illness were clarified by the DSM-iii-R, Iimitations on the DSM-iii-R assessments such as weak correspondence between psychosomatic illness and "psychological factors affecting physical condition" were also found m the present study.

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We had a patient (Case 1) who met the criteria for chronic fatigue syndrome (CFS) after infection and another patient (Case 2) who developed CFS after stress-related disorders. We evaluated the onset, diagnosis and treatment of CFS in these patients from the viewpoint of psychosomatic medicine. Case I developed gastric ulcer when she could not cope with the stress brought about by her shift to another line of work. She experienced chronic fatigue and was admitted to our hospital. After the treatment of infection, we realized that she met the criteria for CFS. Case 2 was treated for somatization disorders by various physical and psychiatric symptoms due to work-related stress and failed romance. The case met the criteria for CFS during the time we followed it. During hospitalization, a rehabilitation program was implemented to deal with fatigue, myalgia, back pain, and muscle weakness of these patients. Psychosomatic therapy such as behavioral counseling and operant techniques for behavior modification were also performed. Case I recovered after 6 months of therapy and returned to her workplace. Case 2 discharged after I month of therapy but her fatigue worsened. After the patient resigned from her job, the symptoms improved and now she is working. Natural killer cell activity decreased in the 2 cases during hospitalization but increased I or 2 months later, after symptomatic improvement. We thought that these cases had psychosomatic diseases based on the identifiable causes of their onset and persistence. Therefore, psychosomatic approaches were indispensable for the treatment of these patients.

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A 51-year-old female was stressed emotionally by a colleague at her place of work. After being stressed she suffered from the persistently severe stiff neck and shoulder, insomnia, disturbed concentration, hyperesthesia on the head, palms and soles, elbow pain in the night, dryness of the eyes. She visited the neurological clinic in the medical college and the neurological doctor diagnosed the case as thalamic syndrome clinically. The findings in the X-ray films of the cervical and lumbar vertebrae and those in CT scan did not show any abnormality. Though she was given hypotensive agent, antianxious agent and vitamin B_1 drug for 2 years, her various complaints remained unchanged. About 4 years after the onset, I have consulted and treated her from the point of general adjusting system including oriental medicine as a doctor of medical check and found edema and venous congestion, especially in the region of the head, face and neck. She was treated by shiraku-therapy once a week. Shiraku-therapy is one of the stimulating treatments originated from oriental medicine and whose method is a slight venesection of 20-30 drops from the meridian point. The dryness of the eyes and eye pain were improved remarkably I minute after shiraku-therapy on the certain meridian point (hyakue) of the parietal region detected by neurometer. The persistent severe stiff neck and shoulder, insomnia, disturbed concentration, hyperesthesia on the head, palms and soles, elbow pain in the night were also improved dramatically by shiraku-therapy on the certain 2 points of occipital region (A-point) which were detected also 'by neurometer. During 14 weeks after gradual reduction and during 25 weeks after cessation of shiraku-therapy she progressed satisfactorily. Besides shiraku-therapy she took only collyrium for dryness of eyes for 8 weeks during treatment of shiraku-therapy and after its cessation. The mechanism whereby the shiraku-therapy on the certain meridian point is effective on various unidentified clinical symptoms caused by mental stress remains unknown.

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